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The campus of SSM Health St. Mary’s Hospital is seen in Madison, Wis., on March 5, 2020. SSM Health signed a $7 million contract with Premier in 2005 to help cut labor costs and analyze productivity at more than a dozen of its hospitals. The company has since given awards to St. Mary’s and other SSM Health hospitals for improving health care quality and costs. Coburn Dukehart/Wisconsin Watch

Madison nurses were already accusing hospital management of putting patients at risk through cuts to staff and supplies.

Then the pandemic struck.

As COVID-19 rapidly spreads across Wisconsin and worldwide, Madison nurses say they are standing in the "calm before the storm," expecting a surge of infected patients to overwhelm hospital systems that sometimes struggle to meet typical demands.

"Not staffed for regular patient levels let alone potential influx of patients," one SSM St. Mary’s nurse wrote in response to a survey distributed by the Cap Times, Wisconsin Public Radio and Wisconsin Watch. "Unless they put patients in hallways or create temporary tent hospitals, I don't know where we would put them."

The nurse was among 14 nurses from St. Mary’s who responded in surveys, interviews and emails for this story. Most asked not to be named because they feared reprisals from hospital managers. Reporters also interviewed nurses in Milwaukee and Monroe and emergency physicians in Madison and Green Bay.

Hospital systems in Wisconsin, like those across the country, could soon be short on beds, protective gear and staff to confront a virus detected in 281 people statewide, as of Sunday morning.

The pandemic is testing health systems that already ran lean while hospital executives turned to data-powered algorithms to slash labor costs by cutting "waste," such as nurses with downtime.

St. Mary’s nurses contacted for this story said they were not sure how to confront the expected onslaught of patients with COVID-19, a mild-to-severe respiratory illness. It can include shortness of breath, fever and cough and carries a relatively high rate of hospitalization.

"We're short on a good day," one St. Mary’s nurse said. "I can't imagine what's going to happen if we have a bunch of our staff get sick and taken out of the picture."

Jennifer Aumanstal, a birth suites nurse at the hospital, said she received messages Thursday and Friday looking for two extra nurses for her unit.

"This is happening over and over, and it's not just because of coronavirus," she said in an interview Friday. "I think this is gonna kind of bring everything to the surface and escalate the issues that we're already seeing."

Madison regional hospitals must triple their number of available beds to handle even a "moderate scenario" in which 40 percent of adult residents become infected over a year, according to a Harvard Global Health Institute analysis based on 2018 data. Milwaukee and Green Bay regional hospitals would each need to more than double their beds to confront that scenario.

The Harvard analysis does not account for hospitals that free up beds, which many are already doing. Demands on hospitals can be further reduced when residents take steps to stay healthy, including thoroughly washing their hands and practicing social distancing.

Wisconsin Watch, the Cap Times and Wisconsin Public Radio asked hospitals, county and state health departments and advocacy organizations for the number of available beds and ICU beds Thursday but no group provided those figures. The state Department of Health Services said Friday in a media briefing that the state has 2,500 total ICU beds and hospitals are working to add to this total but did not provide the number of available ICU beds.

DHS Secretary Andrea Palm told reporters Friday that Wisconsin will receive supplies from a federal stockpile but acknowledged it will not be enough to meet the need if patients surge into hospitals. The state is prioritizing the delivery of those supplies to areas hardest-hit by the virus and first responders who are transporting patients to hospitals. The state is enlisting Wisconsin manufacturers to produce more supplies.

SEIU Healthcare Wisconsin vice president Anne Louise Tetrault, a statewide union representing health care workers, called the protective gear shortage "outrageous" and accused the federal government of a "shameful" lack of action.

"We are asked to fight a war without protective equipment for ourselves and asked to return to our families," she said in a press call Friday.

DHS on Thursday said it would not reveal how many health care personnel have tested positive for COVID-19.

St. Mary’s did not respond to a request for comment on staffing and preparedness policies. It is among many hospitals seeing a deluge of media requests amid the pandemic.

St. Mary’s staffing procedures meet patient needs "across all our ministries — at all times," spokesperson Kim Sveum said earlier this month, before the coronavirus triggered shutdowns to schools and business across Wisconsin.

St. Mary’s nurses described a communication breakdown and poor organization inside the hospital. Nurses said they often learn of new policies through conversations with their coworkers. While the hospital circulates updates internally, nurses say they are often too busy to sit down and read them. One nurse learned about the hospital’s new policy restricting patients to one visitor from TV news.

"When you come in (from a day off), you're completely in the dark," the nurse said.

That nurse said she was exposed to a potential COVID-19 patient weeks ago when the hospital offered little guidance about how to treat such patients. Without protective gear, she tended to the patient who had fever and tested negative for influenza. Then a physician pulled her aside. The physician was ahead of the curve, she recalled, telling her: "assume they have (COVID-19) until they know" otherwise. The nurse now assumes the patient did not have the virus because no one later notified her of that status.

Speaking in a press call Friday, St. Mary’s nurse Brittany Festino said she exhibited symptoms associated with COVID-19 for several days, yet was not tested until Wednesday when testing guidelines changed. The hospital instructed her fiance and fellow St. Mary’s nurse, Nick Zander, to quarantine himself. But Zander was already living and working with Festino while she was sick earlier.

St. Mary’s nurses are broadly told to stay at home if exposed to a confirmed COVID-19 patient without protection. But that guidance highlights another challenge: uncertainty about whether nurses will be paid for time away from work.

St. Mary’s nurses say they previously accrued a pool of paid time off called the "Earned Medical Benefit," allowing them time to take care of themselves or family members. The hospital replaced that benefit in December. Nurses now receive disability insurance that pays only a partial salary and requires approval.

"I’m probably going to have to dip into savings," said a nurse who has been sick with a fever for more than a week but tested negative for COVID-19.

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If her short-term disability request is approved, the nurse says she will qualify for 75 percent salary. Her request is still pending.

SEIU Healthcare Wisconsin on Friday called for emergency sick leave policies at hospitals — to pay affected to stay home, rather than risk spreading the virus within the hospital.

Supply Shortage

St. Mary’s is not alone in struggling to stay ahead of the virus.

A nurse at a Milwaukee clinic fears she, too, is exposed. Her clinic serves many poor and homeless patients who are particularly vulnerable to the virus. But it only has basic supplies: gloves, soap and paper masks. Staff lack N95 masks, spit guards and glasses, she said. When a provider who rotated to the clinic tested positive for COVID-19, staff were not informed for a week, she said.

N95 masks are considered the best protection from the virus, but they are increasingly hard to find nationwide.

Under ideal conditions, Wisconsin’s public health organizations could borrow gear and spread it between hospitals. But that option vanished after a major flu season lessened supplies, said Jennifer Behnke, a coordinator for the South Central Wisconsin Healthcare Emergency Readiness Coalition, which organizes health care and other groups during disasters.

Ryan Thompson, president of the Wisconsin chapter of the American College of Emergency Physician and an emergency physician at UW Health, said Wednesday that his hospital is seeing fewer patients for now — but only after canceling non-essential procedures to prepare for the likely surge in COVID-19 patients.

"The hospital looks the best it has been in weeks," Thompson said in an interview, half-joking.

The state Department of Health Services on Tuesday confirmed "community spread" in Dane County, which means people have been infected with the virus locally, including some whose source of infection is unclear.

Thompson worries a shortage of masks and faceguards will leave UW Health staff vulnerable to catching and spreading the virus. The hospital is asking staff to reuse certain equipment, he said, which can increase the risk of contamination.

Dr. Ryan Westergaard, chief medical officer of the Bureau of Communicable Diseases, said Friday reusing supplies is not "the usual standard," but experts agree is "acceptable" given the circumstances.

Mechanical ventilators, which are in short supply in places like New York, are in "fair supply" at the hospital, he added.

St. Mary’s nurses also expressed fears of a mask shortage. A nurse in the ambulatory surgical center said she was told Wednesday her unit would run out in five days.

Aumanstal said she and several other nurses in her unit could not properly fit their masks, meaning they must use a respirator known as a PAPR for protection. Her unit has just one PAPR, she said. Aumanstal said she was exposed to a coworker who tested positive for COVID-19, but management told her to wear a mask at all times and keep working until she shows symptoms of the virus.

Dr. Shera Teitge, an emergency physician who rotates between several SSM Hospitals in Dane County, said St. Mary’s is taking steps to prepare. The hospital had enough personal protective equipment in its emergency department as of Thursday, she said, but she expects staff to reuse gear during the frenzy expected to come.

St. Mary’s nurse Laura Vowels said Friday she was told her unit had had one month of protective equipment left, which she found reassuring. But the unit is in "scarcity mode," she added.

"We are concerned that while we may have one month of supplies, this is a pandemic that may be six or, based on reports, 18 months long," she said.

Reason For Hope?

There are ways hospitals can stretch resources, said Dr. Vineet Chopra, an expert on infections at Michigan Medicine, the University of Michigan health system.

Earlier this month, Chopra and other doctors offered prescriptions to prepare for COVID-19 in the Annals of Internal Medicine. Those included ways to isolate infected patients to protect staff and conserve other resources — while improving communication with the workforce, patients and public.

Chopra has "borne witness to incredible changes that I have never seen in our health system (or in my professional career, for that matter)," he wrote in an email. His colleagues have freed up dozens of ICU beds, re-arranged the hospital cafeteria to allow for social distancing, and brought staff together twice a day in its command center to transform testing and treatment.

"The key thing has been the message that this is not 'business as usual,' and we need to prepare for the worst while we expect the best," he wrote.

Teitge said Wisconsin holds an advantage: Its hospitals can learn from what has happened in Seattle, New York, Italy and China, where the virus first spread.

She spoke of a "huge amount of knowledge being shared right now."

Behnke, of the South Central Wisconsin Healthcare Emergency Readiness Coalition, said Wisconsin hospitals have spent five years planning how to accommodate a 20 percent surge beyond capacity. If a hospital was normally staffed to handle 100 patients, for instance, it should have a plan and resources to handle 120 patients.

Still, Behnke said, "everyone is afraid of the unknown," such as how many COVID-19 patients they’ll see or whether protective equipment manufacturers will quicken their pace.

Teitge said she expects Madison’s physicians to succeed, but the community must do its part.

"You can stop this by staying home, by following directions, by not going out when you're sick,” she said. “When you need us, we’re not going anywhere."

This story was a collaboration between Wisconsin Watch, the Cap Times and Wisconsin Public Radio. The nonprofit Wisconsin Center for Investigative Journalism (wisconsinwatch.org) collaborates with Wisconsin Public Radio, PBS Wisconsin, other news media and the University of Wisconsin-Madison School of Journalism and Mass Communication. All works created, published, posted or disseminated by the Center do not necessarily reflect the views or opinions of UW-Madison or any of its affiliates.

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